Call us at
701-857-6050
or text us at
701-401-2206

Authorization Release Form

  • Authorization For Release of Identifying Health Information

  • Information to be released:
  • Release information to…

  • It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices.

    When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes.

    I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

  • Max. file size: 1 GB.
  • This field is for validation purposes and should be left unchanged.

Office Hours & Info

  • Monday
  • 8:30am - 5:00pm
  • Tuesday
  • 8:30am - 5:00pm
  • Wednesday
  • 8:30am - 5:00pm
  • Thursday
  • 8:30am - 5:00pm
  • Friday
  • *8:30am - 2:00pm
  • Saturday
  • Closed
  • Sunday
  • Closed

Holiday Hours

Jan 1 - Closed
March 29 - Closing at 3pm
May 27-Closed
July 4-5 - Closed
Sept 2 - Closed
Nov 28 & 29 - Closed
Dec 24-25 - Closed
Jan 1 - Closed (2025)
*Seasonal Hours
Closing at 1:00pm on Fridays in the Summer, May 31 to August 30.

  • 1525 31st Ave. SW / Suite E
  • Minot, ND
  • 58701
701-857-6050 701-857-6052

After-Hours Emergencies:

701-409-0076